Considerations in the management of concussion with an illustrative case example

Craig Chappell, DO, Sports Medicine Fellow, Lake Erie College of Osteopathic Medicine, 5401 Peach Street, Suite 3400, Erie, PA 16509.

E-mail address: cc50cal@hotmail.com.

KEYWORDS:

Concussion; Sport; Neurocognitive testing;

Return to play; Student athlete

Concussions are extremely common injuries, especially among student athletes. With emerging guide- lines that will require physicians to make decisions regarding injured athletes’ return to physical activity, the family physician will soon be faced with more frequent questions from injured athletes and with new responsibilities to help ensure patients’ safety. Assessment tools such as Sport Concussion Assessment Tool and neurocognitive testing will assist with evaluation and return to play decisions, but ultimately, it is important for the physician to develop a strategy for comfortably and appropriately managing this frequently encountered and challenging problem.

‌Current and emerging guidelines

These policy changes will give the family physician an excellent opportunity to make a difference in the health of high school athletes and prevent further injury. It is our intention to use an illustrative case to guide the family physician through the evaluation and management of an athlete who has sustained a concussion. We will also pro- vide a strategy for confident decision making concerning releasing the concussed athlete to return to play.

‌Case overview

During a football game, JT, a 17-year-old male player, sustained a helmet-to-helmet hit during the second quarter while tackling a player from the opposing team. Stunned and complaining of a frontal headache, he continued to play until the half expired. At halftime JT’s teammates reported that he was not acting “normally,” at which point the ATC was notified. Using the Pocket Sport Concussion Assess- ment Tool (Pocket SCAT), the ATC evaluated an uncoop- erative JT. Memory, balance, and symptoms were assessed. JT stated, “I feel fine,” “Leave me alone,” and “I just got dinged.” Based on this information and assessment, he was allowed to return to play during the second half. After the game, JT’s parents stated that their son had not played well and they sensed that he was “not right.” They decided to take JT to the emergency department, where he underwent a CT scan, which was unremarkable. He was diagnosed with a concussion and instructed to follow up with his family physician for evaluation and return to play consid- erations. Three days later, JT presented to his family phy- sician complaining of headaches and light sensitivity. His mother stated that he had been unusually emotional. At this point, JT reported that he may have sustained an additional concussion two weeks before but did not report it for fear he would not be allowed to play.

‌Definition of concussion

‌Discussion

Table 1 Symptoms of concussion

Cognitive

Confusion Posttraumatic

amnesia Retrograde amnesia Loss of

consciousness (4.6%)2

Disorientation Vacant stare Difficulty focusing Delayed verbal and

motor responses Slurred or incoherent

speech

Excessive drowsiness

Somatic

Headache (93%)2 Fatigue

Affective

Emotional labiality Irritability

Disequilibrium Nausea/vomiting

Visual disturbance Phonophobia

Table 3 Neurocognitive assessment option

Name

Axon Sports

(Collie, Assessment and Management of traumatic brain injury)

ImPACT

(Immediate Post-Concussion Assessment and Cognitive Testing)

ANAM

(Automated Neuropsychological Assessment Metrics)

HeadMinder

Source

http://www.axonsports.com

http://www.impacttest.com

http://www.DVBIC.org

http://www.headminder.com

Table 2 PPE questions

Have you ever had a head injury or concussion?

Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?

In the more common scenarios, like the one described here, the physician is seeing the patient hours to days after the event and must glean as much information as possible from the patient and event witnesses about the mechanism of injury and progression of symptoms. This reality was addressed at the same conference in Zurich with the devel- opment of the PocketSCAT2. This tool was developed for the lay person (e.g., parents, coaches, referees, ATC) to

‌Return to play

One of the most difficult decisions the assessing physician must make is when to allow the athlete to return to play. The physician may feel pressure from the patient, coaches, train- ers, and family members to rush return to play decisions, so it is imperative to educate all involved parties about the inherent dangers. This is yet another situation in which good communication and working relationships with the patient, as well as family and coaches, are crucial.

Table 4 Graduated exertion test3

Day 1 Light aerobic Walking, swimming, activity stationary bike

Day 2 Sport-specific Drills, running; no risk of exercise head impact

Day 3 Noncontact training Passing drills with progressive drills resistance training

Day 4 Full-contact Supervised full-contact play practice with team members

‌Conclusion

‌References‌

1. Gilchrist J, Thomas KE, Wald M, et al. Nonfatal traumatic brain injuries from sports and recreation activities—United States, 2001- 2005. MMWR Morb Mortal Wkly Rep 56: 733-737, 2007

   
   

2. ‌Meehan WP, d’Hemecourt P, Dawn Comstock R: High school con- cussions in the 2008-2009 academic year. Am J Sports Med 38:2405- 2409, 2010‌

3. ‌McCrory P, Meeuwisse W, Johnston K, et al: Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. J Clin Neurosci 16:755-763, 2009

4. ‌Gessel LM, Fields SK, Collins CL, et al: Concussions among United States high school and collegiate athletes. J Athl Train 42:495-503, 2007

5. National Federation of State High School Associations: 2008-2009 High School Athletics Participation Survey. Available at: http:// www.nfhs.org/content.aspx?id=4208. Accessed November 8, 2010.

6. National Football League: Teams. Available at: http://www.nfl.com/ teams. Accessed March 23, 2011.

7. Zgonc E: NCAA Sports Sponsorship and Participation Rates Report 1981-82 – 2008-09. Available at: http://www.ncaapublications.com/ productdownloads/PR2010.pdf. February 2010. Accessed March 23, 2011.

8. Aubry M, Cantu R, Dvorak J, et al: Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med 36:6-10, 2002

9. ‌McCrory P, Johnston K, Meeuwisse W, et al: Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 39:196-204, 2005

10. H.R. 1347—111th Congress: Concussion Treatment and Care Tools Act of 2010. Available at: http://www.govtrack.us/congress/bill.xpd? bill=h111-1347&tab=summary. Accessed February 24, 2011.

11. American Academy of Neurology: Position Statement on Sports Con- cussion. Available at: http://www.aan.com/globals/axon/assets/7913. pdf. Updated October 2010. Accessed December 10, 2010.

12. ‌Guskiewicz KM, Weaver NL, Padua DA, et al: Epidemiology of concussion in collegiate and high school football players. Am J Sports Med 28:643-650, 2000

13. ‌Bazarian JJ, Blyth B, Cimpello L: Bench to bedside: evidence for brain injury after concussion—looking beyond the computed tomography scan. Acad Emerg Med 13:199-214, 2006

14. Hughes DG, Jackson A, Mason DL, et al: Abnormalities on magnetic resonance imaging seen acutely following a mild traumatic brain injury: correlation with neuropsychological tests and delayed recovery. Neuroradiology 46:550-558, 2004

15. ‌Broglio SP, Macciocchi SN, Ferrara MS: Neurocognitive performance of concussed athletes when symptom free. J Athl Train 42:504-508, 2007

16. ‌Bernhardt D, Roberts W (eds). American Academy of Family Physi- cians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine: Preparticipation Physical Evaluation, 4th ed. Elk Grove, IL: American Academy of Pediatrics, 2010

17. NCAA Guideline 2i, Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete. Available at: http://media.kansan.com/news/ documents/2010/12/01/NCAA_Concussion_Guidelines_Revised_July_ 2010.pdf Published June 1994, revised July 2004, 2009, July 2010. Accessed

    ‌March 23, 2011.

18. National Football League: NFL announces new sideline concussion assessment protocol. Available at: http://www.nfl.com/news/story/ 09000d5d81e78cc4/article/nfl-announces-new-sideline-concussion- assessment-protocol. February 2010. Accessed March 23, 2011.

19. Sim A, Terryberry-Spohr L, Wilson KR: Prolonged recovery of mem- ory functioning after mild traumatic brain injury in adolescent athletes. J Neurosurg 108:511-516, 2008